Peer Support Services — the Service of the Future…

by Richard Edwards

…and at this rate, it always will be. Ba dum bum. Thank you, thank you…I’m here all week.

North Carolina–attempting to infuse its public system of supports to people with mental illness with a recovery-focused approach, has received Medicaid (CMS) approval to launch a Peer Support Services (PSS) definition.  You can read about it here, starting on page 95. The service, which has been approved in varying models in eleven states, utilizes individuals who have mental health issues themselves, and have successfully maintained their personal recovery, in engaging persons with mental health issues in active treatment.

In the substance abuse field, historically, many substance abuse counselors were, and are, persons in recovery themselves. In my graduate training as a counselor, I encountered many in the SA treatment field who believed you could not be an effective counselor to people dealing with alcoholism and addiction, unless you had a similar background. At the time, I was pretty quick to say that was poppycock–but that was partially because it threatened my role as a professional, without a personal history of addiction and recovery. Over the years, I have come to appreciate that peers in mental health recovery can establish rapport with those they support in a way I will never be able to.  And that rapport is vitally important, because recovery is, in many ways, about showing up–and a qualified Peer Specialist can be particularly effective in helping people see the importance of taking personal responsibility for their health and well-being.

So, from that perspective, I think it’s fantastic that Peer Supports is set to go live in NC in July, 2011.

Unfortunately, Peer Supports may only be “live” in the academic sense–available in theory, but not in practice. Here’s why…

First of all, the rate for PSS ($22/hour) is simply too low to be seriously considered. I’ve spoken with several providers, who all say they would lose significant amounts of money (well over $100k by one estimate) providing this service over a year.  Any provider agency who does their homework will come to the conclusion that the rate is insufficient for the service as it is defined.

Secondly, only CABHA-certified providers (Critical Access Behavioral Healthcare Agencies) can provide PSS, and CABHAs are already straining under the costs of their own infrastructures (see previous post–“Mental Health Reform is Dead!”), not to mention the requirement that CABHAs provide services that also lose money like psychiatric management and outpatient therapy. Given these pressures, it is very unlikely that an organization is going to expand into another service that is so obviously under-funded.

Thirdly, the current definition is very restrictive, and will require intensive management and oversight. For instance–

  • PSS requires a full-time licensed or provisionally-licensed supervisor who cannot bill for any services her/himself;
  • PSS is a short-term service–maximum six months per year, which doesn’t really seem to match up with outcomes typically associated with recovery;
  • PSS has to be provided with outpatient therapy–so only the people you serve on an outpatient basis are eligible, which further limits potential referrals;
  • PSS–because of a weekly, individual supervision requirement–discourages the employment of many skilled Peer Specialists who only want to work part-time; and full-time employment means…
  • Productivity requirements of 60% per week–meaning 24 hours of a 40 hour workweek must be billable activity. Sound easy? It’s actually very difficult when you add travel (this service is community-based); meetings; documentation; supervision; etc…

These requirements may not seem onerous to the casual observer, but add them to insufficient funding, and they present a very high barrier.

Lastly, there are currently few CABHA providers that  have any significant experience with Peer Support Services, unless they have been running an Assertive Community Treatment Team (ACTT), or recovery-focused services such as a Peer Drop-In Center or Recovery Center.  And even if they have been running an ACT Team, they may have as few as one Certified Peer Specialist in their organization.  The point is, few CABHAs really understand Peer Support Services, but they do understand that, poorly handled, the well-being of the people supported, and the people employed, is at risk.

Ironically, many of the peer-run organizations who have the most experience and skill at providing and administering peer support services aren’t qualified to deliver Peer Support Services under the new definition, because they don’t have a Medical Director, a Clinical Director, and a QM/Training Director (i.e., they are not CABHAs).

So, for now at least, the future of PSS in NC remains, well, in the future. And while this might sound like I blame the authors of the defintion at the state, that is absolutely not the case. Service definitions, like the one for PSS, are really not so much definitions as they are conversations, and they occur over years, even decades, between persons served, providers, advocacy organizations, state and federal governments, and the general public.

So rather than throw up my/our hands, my angle is that we need to take the long view on peer support services, because the potential upside for people with mental health issues–indeed all people with disabilities–is too great to be ignored. The current service definition and the accompanying rates–inadequate though they are–are part of the process of bringing these supports to NC’s citizens dealing with mental illness. And this means committing to staying at the table of making peer support services a reality today, with or without the defined service.

But that’s just my angle–what are your thoughts?

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: